LOWER RESPIRATORY TRACT INFECTION

Dr. Hayat Z Kamfar

Assisstant Professor& Consultant Pediatrician

Learning Objectives:

After completing the lecture students should be able to:

Identify common lower respiratory tract infection during

childhood
describe the findings of pneumonia on phy. examination of

different age group and of bronchiolitis in infants

name the most important cause of bacterial pneumonia in

children older than 6 months of age

delineate the differential diagnosis of atypical pneumonia in

school-age children and adolescents

describe the treatment of pneumonia and bronchiolitis in

infants and young children

characterize the circumstances under which a follow-up

chest radiography is required for pneumonia

Introduction Clinical syndromes: 15% croup 34% tracheobronchitis 29% bronchiolitis 29% pneumonia

Overall attack rate of pneumonia in all ages was 4-6 cases/100 children/year

BRONCHIOLITIS PNEUMONIA

Pneumonia .continue

Pathphysiology
Clinical manifestations:
Cough Grunting Chest pain Tachypnea Retraction Auscultation Cyanosis

Additional clues:
Chest radiograph Laboratory tests

CLINICAL PRESENTATIONS:
Newborn Infants (1-6months) Toddlers/preschoolers(7m-5y) Child/adolescent(6y-18y) Well-appearing Ill-appearing

NEWBORNS:
An infant is grunting on arrival in the nursery from the delivery room. He has a respiratory rate of 75 b/min and substernal retractions. Pulse oximetry on room air is 85%, and he has fine crackles on auscultation. Chest radiograph demonstrates a ground-glass appearance with air bronchograms. He appears ill.

Group B streptococcal disease-most commoncause of LRI in newborns Most likely in utero acquired infection Affected infants frequently develop fulminant illness-hours of delivery Fatal if not detected early Initial therapy includes mechanical support- if necessary- and I.V antibiotics: Ampicillin (100mg/kg as initial dose 200mg/kg/24hrs) Gentamycin (2.5mg/kg as initial dose 7.5mg/kg/24hrs)

INFANTS: A) FEBRILE/ILL APPEARING: A 3-month-old child develops mild cough and nasal discharge. On the forth day of the illness, she stops feeding, cough becomes prominent, and temperature rises to 102 F (38.8 C). Physical examination reveals a respiratory rate of 60b/min, sternal and substernal retractions, and diffuse crackles. A lobar infiltrate is seen on chest radiograph.

High fever in an infant is more likely to be the result of invasive bacterial disease
Pathogens in this age group include: Streptococcus pneumoniae Haemophilus influenzae serotype B (HIB) Staphylococcus aureus (suggested also by the presence of pleural effusion or pneumothorax on presentation) Approach to a febrile infant suspected to have bacterial pneumonia should include full septic screen Infants with febrile pneumonia should be hospitalized and initial parenteral antibiotics should include: Nafcillin or flucloxacillin (100mg/kg/24hrs) Cefotaxime (100-150mg/kg/24hrs) or cefuraxime (100150mg/kg/day)

B) Afebrile/Well appearing
A 2-month-old girl presents with progressive coryza, cough, and difficulty feeding. She has paroxysms of "staccato" cough with nasal congestion and respiratory rate of 55 b/min. Her temperature is normal. Auscultation of the chest reveals diffuse rhonchi and coarse crackles. There are mild subcostal retractions. Chest radiograph demonstrates hyperinflation and diffuse, increased interstitial markings. The infant appears well. She is feeding, playful, and smiling.

Most commonly identified pathogens are Chlamydia trachomatis, Ureaplasma urealyticum, cytomegalovirus and Pneumocystis carinii. RSV, adenovirus, and parainfluenza viruses also can cause pneumonia in otherwise well infants. Bordetella pertussis should also be expected even if there is no characteristic "whoop". Infants who have afebrile pneumonia often will be evaluated and treated in an outpatient setting. Inability to eat, respiratory distress, and hypoxemia are criteria for hospitalization. Although viruses cause the majority of LRIs in this age group, but if Chlamydia or B.pertussis expected the drug of choice is erythromycin (50mg/kg/day)- an alternative is sulfamethoxasole (septrin) at (50mg/kg/day) for a total of 7-10 days.

TODDLERS/PRESCHOOLERS: A) febrile/well appearing: An 18-month-old child has an 8-day history of progressive nasal congestion, coryza, hoarseness, and cough. The cough is worse at night. She has had occasional post-tussive vomiting. In fact, the emesis is the parent's chief complaint. Her cough sounded "tight" initially but now sounds "wet". She had a "low-grade" fever initially, but now is afebrile. Two siblings are sick at home with "colds". Auscultation reveals diffuse heterophonous wheezing and inspiratory crackles. The child otherwise appear well.

The vast majority of pneumonia among toddlers and preschool children results from viral infection Etiologic agents followed seasonal pattern: RSV in rainy, winter months Parainfluenza in the late summer and autumn (when croup also seen) Influenza with epidemics in winter Daily outpatient follow-up after the initial diagnosis of viral pneumonia will ensure that no patient, who develops a more severe, secondary bacterial infection will be missed

B) Febrile / ill appearing

Following 2 to 3 days of a relatively minor cold, a 4-year-old child has acute onset of fever to 39C and chills. He has a productive-sounding cough. Examination reveals no retractions, but a respiratory rate of 40 b/min and fine crackles in the area of the left base. Chest radiograph demonstrates a "round" infiltrate in the left lower lobe. The child is ill appearing, but he is alert and cooperative and is in no respiratory distress.

Pneumococcus is the most common bacterial pathogen causing febrile pneumonia in children and adults The clinical syndrome is characteristic and distinctive : acute onset of high, spiking fever, with chills, cough, and sputum production Leukocytosis frequently will be present on the blood count Chest x-ray will reveal a typical lobar pneumonia, a small parapneumonic effusion can be present Neisseria meningitidis infection also may present with same picture of febrile pnemonia, but it usually is accompanied by signs of meningococcemia Outpatient therapy is sufficient for an otherwise healthy, alert, and cooperative child, but the patient should be followed daily

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Antibiotics of choice is: Penicillin VK (25-50 mg /kg/day as TID) Amoxacillin 40mg /kg/day as TID) Patients who does not tolerate oral medication, may benefit from initial dose of I.M ceftriaxone (50mg/kg with lidocaine) Hospital parenteral antibiotics is reserved for severely ill, and/or who has evidence of respiratory insufficiency Aerosolized bronchodilators (children who have wheezing, a strong F/H of asthma or allergy, or signs of airway obstruction) If hypoxia is present hospitalization, nasal oxygen, and I.V penicillin (150,000U/kg/day as QID) or ampicillin (100mg/kg/day as QID). Cefuraxime (150 mg/kg/days TID)

CHILDREN/ADOLESCENT

A) febrile/well-appearing
A 12-year-old develops mild cough and headache that progresses with the onset of abdominal pain and vomiting. After 48 hours, the cough becomes productive and she develops left-sided chest pain. She also has ear pain. Examination reveals a temperature of 38C, a respiratory rate of 28 b/min, and crackles in the mid-left lung field. Palpation of the trachea causes a paroxysm of cough. Chest radiograph reveals bilateral interstitial infiltrates.

Atypical bacteria are responsible for a significant proportion of LRT disease in adolescent and school-age children Mycoplasma pneumoniae and C. pnumoniae are the identified pathogens M. pneumoniae is highly contagious and tends to affect up to 75% of susceptible household contacts No single characteristic clinical or radiological picture of atypical pneumonia in older child Prodrome of headache and abdominal symptoms has been described often Onset usually is insidious, and fever is of low grade CXR may show lobar infiltrates, bronchopneumonia, or even pleural effusion Cold agglutinin will be detectable in 50% of patients who have M. pneumoniae infections Specific serologic studies for mycoplasma and chlamydia are available

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Both pathogens are susceptible to erythromycin, esteolate form often is tolerated better than the ethylsuccinate form Recommended dose of the estrolate form is 30-40 mg/kg/day as TID or BID Tetracycline (25-50 mg/kg/day as QID) and doxycycline (2-4 mg/kg/day as BID) also effective and can be used in children > 8 years old Azithromycin is effective, but not recommended for children < 16 years A significant number of adolescent and young adults are susceptible to B. pertussis infection (immunity up to 18 years after routine vaccination is only for 80%). This should be suspected especially if paroxysm of cough prolonged > 2-3 weeks Pertussis is a self-limited infection in this age group

B) Febrile/Ill appearing: A 15-year-old boy who has static encephalopathy and psychomotor delay develops fever to 39C and cough. The parents report that he often appears to "choke" on both food and his own secretions. The patient has poor oral hygiene, inflamed gums, and several cavities. Crackles can be heard over the posterior lung field. Chest radiograph reveals consolidation and a cavity with an air-fluid level.

Pulmonary abscess is considered to primary- in

otherwise healthy patients and secondary- in neurologically impaired or immunocompromised patients. 75% of all primary abscesses are complications of

staphylococcal pneumonia.
Secondary abscess may be caused by pneumococci or alpha-hemolytic streptococci. More often polymicrobial and involves anaerobic organisms. All pulmonary abscesses must be treated with parenteral antibiotics until resolved.

Continue. For primary- cefuraxime (150 mg/kg/day as TID ) or ticaracillin/calvulante (300 mg/kg/day as QID) For secondary - clindamycin phosphate (30 mg/kg/day as QID) or ticaracillin/calvulanate. Surgical drainage is a treatment of exception, considered only in patients who remain symptomatic and febrile for > a week on appropriate therapy Occasionally, foreign bodies could be the cause for unresolved abscess- bronchoscopy.

BRONCHIOLITIS
Definition

Epidemiology
Common causes: RSV (commonest) Parainfluenza virus Influenza type A virus Adenovirus Rhinovirus Mycoplasma pneumonia

Pathogenesis

Clinical manifestations:
H/O U.R.T.I. Poor feeding Fever Tachypnea Tachycardia Cyanosis (severe cases) Restlessness Otitis media Nasal congestion Chest findings

Diagnosis
Management: Symptomatic and supportive Antiviral (ribavirin) ??steroids ?? bronchodilators prevention

Sammary : lower respiratory tract infection is a

common medical problem in pediatric age groups

bronchiolitis and pneumonia is a frequent

clinical presentation in young an old children

most of these cases are due to viral

infection, however, some severe cases may need hospital management and close observations

Sammary continue.
most of these cases diagnosis depends on clinical presentation and minimum laboratory and radiological investigations may be needed most of these cases recovered smoothly with appropriate management unless an underlying lung pathological or systemic disease may worsen the condition or continue with chronicity appropriate follow-up of these patients in OPC is appreciated especially after discharge from hospital